A nurse in the emergency department is caring for a 52-year-old male client experiencing chest pain. Below are the exhibits to guide your answer:
Complete the diagram by dragging from the choices below to specify:
- The condition the client is most likely experiencing.
- Two actions the nurse should take.
- Two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Condition: Myocardial infarction.
2 actions:
Administer oxygen via nasal cannula 2 L/min,
Request a prescription for aspirin 325 mg.
2 parameters:
Vital signs,
Electrocardiogram (ECG) rhythm.
Rationale for correct condition: A myocardial infarction is indicated by the elevated troponin levels and ST elevation on the ECG. The client’s symptoms of chest pain, elevated heart rate, and low oxygen saturation support this diagnosis. Prompt identification and treatment are crucial to minimize heart damage. The medical history of hypertension and coronary artery disease increases the likelihood. Immediate interventions can significantly improve outcomes.
Rationale for actions: Administer oxygen to improve oxygenation and reduce myocardial workload. Requesting aspirin helps prevent further clot formation. Morphine alleviates pain but may obscure symptoms, making it less urgent. Nitroglycerin relieves chest pain by vasodilation but is secondary. Verapamil is less immediate for acute myocardial infarction management. Vital signs reflect hemodynamic status and response to treatment. ECG rhythm detects ongoing ischemia or arrhythmias. Monitoring WBC count is less relevant acutely. Platelet count is stable; not the focus in immediate management.
Rationale for parameters: Vital signs ensure hemodynamic stability and detect hypotension or shock. ECG rhythm monitors arrhythmias and ongoing ischemia, critical in myocardial infarction. WBC count indicates infection or inflammation, less immediate concern. Platelet count is important for bleeding risks but less immediate. Chronic stable angina presents with predictable, non-severe pain. Ischemic stroke symptoms differ; focus on neurological deficits. Cardiogenic shock would present with more severe hypotension and signs of organ failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Chest pain is not typically associated with benign prostatic hyperplasia (BPH). BPH affects the prostate gland, leading to urinary symptoms rather than cardiovascular symptoms.
Choice B rationale
Joint stiffness is not a symptom of BPH. Joint stiffness is more commonly associated with musculoskeletal conditions such as arthritis.
Choice C rationale
Frequent urination is a common symptom of BPH. The enlarged prostate gland can press against the urethra, causing increased frequency of urination, especially at night.
Choice D rationale
Blurred vision is not a symptom of BPH. Blurred vision can be caused by various conditions affecting the eyes but is not related to the prostate.
Correct Answer is A
Explanation
Choice A rationale
Radiating pain to the left arm is a classic symptom of a myocardial infarction (MI) due to referred pain from the heart.
Choice B rationale
Shortness of breath can also be associated with MI but is not as specific as radiating pain to the left arm.
Choice C rationale
Headache is not a typical symptom of an MI. It is more commonly associated with other conditions.
Choice D rationale
Nausea and vomiting can occur with an MI but are not as specific as radiating pain to the left arm.
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